Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Thursday, February 07, 2008

With apologies to Etotheipi for the squiggily lines, I have to post this case from my night shift last night. This patient arrived via EMS with "indigestion" at 3 am and was by all accounts a real prick. He was demanding to see to doctor immediately and also demanding morphine, Versed and ice chips. This may seem like a fairly straight forward case.....but you'll love the twist! Read on.

The nurse brought me the EKG which they got immediately per protocol and since he was having an acute inferior wall MI (myocardial infarction) = heart attack, I went straight to his room. There I found a demanding, "I know more than you do" kind of patient who insisted on morphine. His heart rate was in the upper 50's at the time and his systolic blood pressure was about 100. Being astute, I figured that his inferior wall MI also involved his right ventricle so I wanted to be careful about my treatments..especially nitrates, or anything else which might drop his blood pressure. I almost ordered a right sided EKG, but the tech was already gone and I didn't want the hassle of getting her back....plus it wouldn't have changed my management.

I ordered 2 mg of morphine which the patient informed me was an insufficient dose and his pain was 10/10. I explained that he was having a heart attack, and I knew that 2mg wouldn't relieve his pain, but I was trying to "take the edge" off a bit while we got a nitro drip, aspirin, heparin and the other things started. I explained that I didn't want to MASK his pain, but rather to treat the cause, saving his heart muscle being more important to me than his pain. The cardiologist was en route and we should have him in the cath lab in the next 3o minutes or so to get his artery open. I was very patient and explanatory. He on the other hand, demanded some Versed (4mg to be precise) and more morphine ("at least 8 mg"). I knew that we were going to have serious blood pressure problems with this guy, and morphine and Versed weren't gonna help that. I really just wanted to get my low dose IV nitro drip going and see if I could help the pain and improve his overall situation.

Somehow, the nurse misunderstood me and gave the guy a sublingual nitro! The ER docs reading this already know what happened next....his BP dropped to 66/35 and his pain increased, he looked like hell, continued demanding ice chips in addition to his other drug demands He criticised us for "not addressing his pain".

I stayed at his bedside while we pushed the fluids to try and raise his blood pressure. In my nicest and most patient voice possible, I ordered 2 more mg of morphine (even as he protested that the dosage was insufficient). I sat at his bedside and in my best Marcus Welby impersonation, I explained that I'd give him every mg of morphine and Versed we had in the ER if I thought it was the right thing to do....but I didn't. I explained my limitations due to his heart rate and blood pressure. I explained that I really wanted to get nitro started, and unfortunately couldn't use Beta blockers since his heart rate and blood pressure were already so low. I understood his ice chip demands, but I explained that he'd be going to the cath lab very soon, and keeping him NPO was a better strategy at the moment. Like I said, this guy was sick as hell, but he was also a complete prick.

As a way of conversation, I asked what he did for a living (and here's why I'm presenting this case) and he told me that he was a JCAHAO (Joint Commission for the Accreditation of Health Care Organizations) examiner. Turns out he was in one of the little towns nearby doing a survey (torturing the shit out of the staff by nit-picking every little unimportant detail). Well, this was an interesting turn of events!

So, I asked him what he did BEFORE he went to work for JCAHAO (he seemed to "know" a lot about medicine, so I wondered if he was a physician in his previous life). He told me that he had previously been a hospital administrator! I couldn't help myself, nor hold my tongue....I said "so you went from being a hospital administrator to being a JCAHAO examiner"? "That's right" he said. "So, have you ever done anything useful?" was my reply.I got a real "go to hell" look from this guy, but I figured that I could out run him, and he wasn't going to think fondly of us anyway since I wouldn't drug him up over trying to treat the cause of his pain.

Within 1/2 an hour, his pressure was 99 systolic with the fluid boluses, the cardiologist arrived, and off the guy went to the cath lab where he got two stents and reportedly became pain free as soon as his artery was opened.

So, I took a couple of lessons home from this case. First (no surprise): The JCAHAO folks don't give a tinker's damn about good or reasoned medicine....they just want the stupid pain scale addressed. Second (no surprise), many of the examiners are kooks. Third (ALSO no great surprise) even though my nurse inadvertently tried to kill this guy....as 911 has so eloquently stated....they're harder to kill than cockroaches!

For the sake of completeness.....the patient is now doing well. His door to balloon time at 3am was about 40 minutes....not excellent, but not bad either considering the time of day.I'd have to say that this was more Karmic (if that's a word) than taking care of my dentist (who had done a root canal on me about 2 months before) when he got epididymitis!

Gearing up for another couple of exciting night shifts. Gotta nap now..........

26 comments:

oh, that went down like a fine steak with a smothered baked potato and a nice lager. still tasting it. mmmmmmm. i bet he makes much more money than you. that makes me throw up in my mouth a bit but still, yummy.

Nice post. Nothing sums up, for me, the difference between the UK and the US better than the phrase "door to balloon at 3a.m 40 minutes... not excellent". Where Shroom works, a large University teaching hospital, a regional centre for interventional cardiology, there is NO balloon out of hours. None. Ever.Go figure

HaHa military medicine has administrator types also, in the Navy theyre called "Medical Service Corps" which also includes optometrists and physical therapists. I always loved to see them try to explain what their job was to non-medical people. They sounded like that guy in the "Office Space" movie, trying to avoid getting fired.

We had an MSC type on the carrier on which I served back in the mid 80's. After he hammered me for being a fat-boy (in the day when the Navy wanted everyone to look like Tom Cruise, a la, "Top Gun"), I asked him the same question that ERDOC asked, "Have you ever done anything worthwhile for the Navy, like...well, get a ship underway or something like that? Because that's my job. I like Wardroom chili at 0200, suck up neutrons, and as long as the Old Man has steam and electricity, he really doesn't care if I look like Tom Cruise, so why should you?" He really got bent with that for some reason.

Anyone still use droperidol for acute asshollism? Its got a blackbox warning so probably not the best choice for a cardiac patient, but it does give a nice "elphant hit by a tranquilizer dart effect" that is useful at times. For some reason it was the only antiemetic I had at my Gulf War batallion aid station so I got used to giving it for various things, especially as an adjuct to our 50 year old morphine surrettes.

You know how people are afraid to send food back in a restaurant for fear the cook will spit on it? Shouldn't patients in a world of hurt avoid antagonizing the doc who is going to authorize their drugs? Personally, I'd be afraid to sue the doctors of John Ritter for fear of ever getting sick myself. The world of medicine is getting curiouser and curiouser.

Oh man, I was the worst for vandalizing someones steak back in my teenage fry-cooking days, especially if you had the gall to call me out to your table to hear your complaint. The worst was some 95 year old fossil who complained that her chopped steak was too stringy. Lets just say the secret sauce she got wasn't FDA approved.

Frank: I still occasionally use Drop. You're right it's a GREAT drug. But every time I order it, I have to wait for pharmacy to send it up, and there's the inevitable call from the Sri Lankan pharmacist on duty to notify me of the "black box" warning. So it's just more of a hassle than it's worth. CAT still uses it apparantly without too much trouble. BTW, your "special sauce" comment has me wanting to avoid any restaurant-forever! YUK!

WARNING....KINDA TECHNICAL STUFF FOR NON-MEDS (SEE BELOW):

For those who don't know what we're talking about, let me give you a little background. There's a great antipsychotic drug that'll generally take down an elephant at 50 yards (which applies to some of my patients).

It's generally safe, but there's the occasional bad side effect...like death (I hate that side effect).

Over 10 years, the company that produces it recorded less than 100 deaths, but it saved the reports. Once their exclusive patent on Droperidol ran out and it became cheap and generic (they came out with a new drug (Geodon) which they presented with great fanfare!

The drug company turned all of the accumulated deaths from Droperidol to the FDA at one time making their own drug look dangerous. They knew that the pinheads at the FDA would over-react and place a "black box" warning on the drug. Now, it's in the PDR and other drug books as a "dangerous drug", and it's use is "strongly cautioned" in a big black box. So if I use it and have a bad outcome....I'm screwed because some John Edwards type scum sucker will show that to the jury and say "My Daaadddy worked in a meeeeul (mill) and doctor, didn't you know the current literature says that this drug is dangerous?" He'll show the black box warning from the FDA to the jury on a huge projector, and not being tuned in enough to understand the issues here, the jury will fry me. You can't argue science with an uneducated jury who assumes that medical literature is free of bias and the FDA is looking out for good patient care

Without being too technical, the new drug Geodon is actually MORE likely to prolong the QT interval than Droperidol was (that's a heart thing that caused most of the deaths of the folks over last 10 years). So now instead of using the cheap generic Droperidol, we're sort of "urged" to use the more expensive (and in my experience less effective) branded Geodon instead. Very smart (and sleezy) on the part of the drug company, but another pain in my ass.

By the way, this is the same stuff that's going on with pediatric cough and cold meds. They record 50 to 100 deaths and run to the FDA....we're forgetting the DENONIMATOR here (no Etotheipi...this isn't a hot chick with a riding crop decked out in leather) it's the number of times the med is used.

I hate any unnecessary death, but 0.01% is acceptable in my book. There's a greater risk with this frickin' tPA that we're all pushing for strokes!

TECHNICAL STUFF OVER:

My favorite Drop story was the Friday night I had 3 young ladies present with a variety of "maladies". They all worked at a local chicken processing plant and were all dressed for partying (they wanted work excuses for the night). Two of them were fine and were dismissed with instructions to return to work. The third had a "migrane".....and after Droperidol, her "migrane" was better...but she wasn't doing ANY partying that night since she was stone cold out!

Kacey: Despite my bluster and bravado on the web, I'm gonna do what's right for the true emergency patient. This guy was having "the big one" as Fred Sanford used to call it. I would have happily given him morphine and probably some Versed if I could have....it would have been proper medical care....AFTER the other more correct and useful meds had been given. His BP limited my treatment. Still, it's not a good idea to be a prick to the ER staff....it certainly doesn't get you seen faster and it certainly doesn't get you more drugs!

When I have a non-emergent prick patient, their chart goes to to the back of the "to be seen" rack. Everytime they bitch, their chart gets moved further back.

The nurses will actually come to get you and say "this lady and her family are so sweet, and she has xxxxx, could you please go see her next".

ndenuz: I forgot to answer your question. BEFORE he was an administrator, he was a CRNA. You're right though. When they name drugs, or dosages, they immediately go into my "drug seeking file".

I borrowed a page from other docs a few years ago and I started sending letters to folks' PCPs asking for a letter to keep on file verifying that patient X needed to be in the ER 8 times a month for a shot of Demerol. I have NEVER gotten one! Come to think of it, I haven't even gotten a response.

I practiced in close proximity to an Italian public hospital in the 90's and overall was impressed with the care and the hotness of the nurses. I especially liked how you could smoke almost anywhere in the hospital. Access to specialists was a little dicey, the one Neurosurgeon left for holiday for most of July and August, so you might want to schedule your closed head injury accordingly.

I'm not sure exactly how it worked, but there was a box-office looking place on the main floor of the hospital where Italians went to request specialist referrals. Looked all the world like the line at a movie theatre. Around 10am they would meet their limit for the day, and everyone in line would leave peacably. I don't think that would work very well in the US.

Hell yeah, the pizza was great, thats all I ate. Not sure about needing a razor, but the Italian women loved americans. My Navy job allowed me to wear a flight suit, and Navy Pilots pick up even more women than doctors do. Everything was fun and games until the other Marine squadron flew into a ski lift and killed some of the locals, made things a little uncomfortable when we'd go to the local bars. Northern Italian guys are wimps though, its a sad state of affairs when a guy like me can beat up everyone in the bar. The best thing about the italian hospital was the nurses still wore those "Flying Nun" caps, very hot.

There's just one part of this story that doesn't quite ring true for me: the guy didn't demand special treatment BECAUSE of his power and rank. Or wait a minute...maybe that makes sense, too. I take it back.Based on my years as an ICU nurse, a person's "prick"-rank (male or female) tended to be inversely proportional to their actual power. The head of the medical school, the surgeon who was also on the big city hospital authority, the DON...all were wonderful, considerate patients and coworkers, with no need to snarl.

Huh.. I came here from Nurse K's blog (been reading it all day long!) and the part on Geodon caught my eye = and the "black box warning" on the "horrible" drug.. interesting as I take geodon. Now to start looking up stuff :) Much obliged.